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  Table of Contents  
Year : 2016  |  Volume : 53  |  Issue : 1  |  Page : 135-137

Practice of stereotactic body radiotherapy in a developing country: Perception, aspiration, and limitation - A survey

Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India

Date of Web Publication28-Apr-2016

Correspondence Address:
J P Agarwal
Department of Radiation Oncology, Tata Memorial Centre, Mumbai
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-509X.180864

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 » Abstract 

Background: Stereotactic body radiotherapy (SBRT) is an effective and established modern technology now used more commonly. Radiation oncology personnel's (ROP) opinion toward SBRT in the developing countries like India is unknown. Subjects and Methods: A 30 question survey evaluating ROP's profile, technological details, and SBRT's perceptive were seeked. Tata Memorial Center – ROP's email database was used. Results: Survey questionnaire was emailed to 500 ROP's and 224 ROP's were contactable. Majority of the responders were from corporate hospitals and half of responders had experience of 5 or more years of experience in radiation oncology. SBRT was practiced by 70% of responders and the majority had adopted SBRT in 2010 or later. Quick turn around time, high dose delivery and competitive market forces were major factors to adopt SBRT. Lung was the most common site practiced followed by prostate, spine, and liver. All SBRT users were keen to increase SBRT in practice and the majority of non-responders were planning to adapt SBRT in the recent future. Almost half of SBRT users were willing to share data and expertise for training others. Lack of infrastructure was the prime reason for not practicing SBRT. ROP's perceived physics, radiobiology as the biggest challenge in SBRT. International collaboration may be helpful. Conclusion: Use of SBRT is expected to increase in India. Limited experience with lack of infrastructure in public funded centers is a major limitation. Unmet need of infrastructure, training and guidelines is enormous and formulation of Indian SBRT consortium will help reforming at all levels.

Keywords: Developing countries, stereotactic body radiotherapy, survey

How to cite this article:
Rathod S, Munshi A, Agarwal J P. Practice of stereotactic body radiotherapy in a developing country: Perception, aspiration, and limitation - A survey. Indian J Cancer 2016;53:135-7

How to cite this URL:
Rathod S, Munshi A, Agarwal J P. Practice of stereotactic body radiotherapy in a developing country: Perception, aspiration, and limitation - A survey. Indian J Cancer [serial online] 2016 [cited 2022 Aug 17];53:135-7. Available from:

 » Introduction Top

Modern radiation therapy comprises of state of art techniques as stereotactic body radiotherapy (SBRT) in which high dose of radiation are delivered to the target with a single dose or small number of fractions with a high degree of precision. SBRT requires higher levels of accuracy and coordinated team effort amongst radiation oncology personnel's (ROP).

Over last few years, use of SBRT is increasing in clinics. Lung, liver, prostate, bone are major sites practiced with SBRT in curative and palliative settings.[1],[2],[3] Recently, practice patterns of SBRT have been published from developed countries.[4],[5] Unfortunately, no such practice patterns are available from developing countries. This survey was conducted to find patterns of SBRT practices amongst ROP's in India.

 » Subjects and Methods Top

A survey questionnaire comprising of 30 questions was developed. ROP's were inquired about their background information/practice patterns/experience with SBRT. Non-users were asked about reasons for not adopting SBRT and their future plans regarding SBRT.

Tata Memorial Center - Radiation Oncologist email database was used to contact ROP's. Between October 2012 and March 2013, survey questionnaires were sent through email to 500 ROP's. Data was collected until April 2013.

SPSS version 20 was used for statistical analysis. The survey results are presented as the percentage of evaluable responses. Differences in percentages between groups were analyzed using Chi-square tests.

 » Results Top

Population characteristics and expertise

Survey questionnaire was emailed to 500 ROP's. Emails were delivered to 224 ROP's whereas 276 ROP's were not contactable as email delivery was failed. Fifty-three ROP's responded to survey questionnaire. Thirty-seven (70%) responders were from corporate hospitals, whereas 16 (30%) were from public hospitals. Thirty (57%) responders had academic institutions affiliation, whereas 23 responders (43%) represent non-academic institutions. Among responders 26 (49%) had experience of more than 10 years, 10 (19%) had experience of 5-10 years, whereas 17 (32%) had experience of less than 2 years.

Amongst the survey population, 17 (32%) ROP's were practicing SBRT in clinics of which 5 (29%) were practicing SBRT prior to 2009 and rest all adopted SBRT 2010 or later. Amongst SBRT users 9 (54%) had more than 10 years of radiation oncology experience. Mean duration of experience with SBRT was 2.8 years (range 1-6 years). SBRT was more commonly practiced corporate centers as compared with go in the public institutions (42% vs. 6%; P = 0.01). SBRT was more commonly practiced in non-academic centers than academic although the difference was not statistically significant (39% vs. 27%; P = ns). Among SBRT users, only 4 (24%) practiced SBRT as major expertise. Demographics are shown in [Table 1].
Table 1: Demographics

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Drivers for using SBRT

Ability to deliver higher radiation doses than conventional was most common reason (83%) for adaptation of SBRT in practice. Another major reason (18%) for adopting SBRT was to gain competitive advantage or remain competitive in practice. About 12% and 6% users cited clinical research or retreatment as a major factor respectively. Refusal to surgery was most common (20-80%) reason for SBRT referral. Unfit for surgery and medical comorbidity were next common reasons for SBRT referral.

SBRT practices

Lung (83%) was the most commonly practiced site followed by liver/bone/prostate/adrenals which were less commonly practiced. SBRT users treated average 4.5 (range 1-75) patients per year. ROP's practicing SBRT as major specialty treated average 31 patients per year.

SBRT planning and prescription

All users report use of immobilization device in SBRT. Vacloc-body fix was most commonly used 13 (77%) immobilization device. Responders reported infrequent use of body frames, thermoplastic molds, blue bags etc.

Contrast enhanced computed tomography (CECT) was most commonly 9 (53%) used imaging modality for target delineation. Hybrid imaging modality was preferred was delineation. CECT-magnetic resonance imaging (MRI) fusion was commonly used modality 9 (53%) followed by CECT-position emission tomography (PET) fusion 5 (30%). Triple imaging modality CECT, MRI and PET fusion was uncommon.

For thoracic and abdominal sites suitable methods to account respiratory motion was used by 13 (77%) responders. Motion management methods 4 (24%), Shallow breathing with abdominal compression 3 (18%), Real-time tracking methods were common 3 (18%) were used commonly.

No consensus was noted in isodose line prescription patterns and it ranged from 70% to 95%. Prescription at specified isodose line was more common 7 (41%) than isocenter prescription 3 (18%); whereas 10 (58%) SBRT users did not respond to this question. Arc (fixed or dynamic) was preferred SBRT planning technique (58%), followed by IMRT (30%).

Target localization imaging was done by all ROP's before each treatment fraction. In room volumetric imaging was used most commonly 9 (53%), real time imaging was next common 5 (30%). In room planar imaging was least 1 (6%) used.

Challenges in SBRT

Survey suggests ROP's perceive quality assurance 15 (28%) and radiobiology 13 (24.5%) as the biggest challenge in SBRT. Physics, immobilization, delineation, image guidance were other infrequent challenge.

Future prospects of SBRT in clinics

Among SBRT users 16 (94%) were planning to increase the use of SBRT in the practice. Educating physicians/teaching SBRT to surgical collogues/informing patients regarding SBRT can be ways to increase the use of SBRT in clinical practice. In surveyed population, 70% ROP's feel all the above approaches can be used to promote SBRT, remaining 30% population favored the use of any one method for promotion.

SBRT non-users

Of 36 SBRT non-users, 30 (83%) were unable to practice SBRT due to lack of necessary infrastructure. Of which, 4 expressed a lack of necessary diagnostic modality, whereas 26 expressed lack necessary treatment setup as reason. Amongst SBRT non-users, 22 were from academic institutions than 14 from non-academic institutes.

Thirty-four SBRT non-users (94%) were planning to adapt SBRT in their practice. Ability to deliver higher radiation doses over conventional was quoted as most common 27 (75%) reason for the plan to adopt SBRT. Retreatment was second most common reason 4 (11%) in surveyed population.

Follow-up and future directives

Surveyed ROP's 25 (48%) feel the need for adjuvant treatment after SBRT. Of surveyed ROP's 45 (85%) expressed the need of SBRT consortium in India. To question of sharing SBRT data 56% responded positively. ROP's had no consensus on follow-up protocol policy (timing of 1st follow-up; frequency of subsequent follow-ups; imaging modality at follow-ups). Timing of first follow-up varied from 6 to 12 weeks. No agreement was noted on imaging policy at follow-up.

 » Discussion Top

Though modern technologies like SBRT are adopted rapidly in developing countries like India in last few decades, there is a general paucity of data from India regarding SBRT practice patterns.[6]

Survey with emails is a useful tool. This electronic module is cheap and expects early responses. In resource limited setting such surveys will be good alternative. Compliance rate to surveys is a limiting factor and in our survey 24% ROP's responded to survey. Reasons for non-response to survey could be busy schedule, general apathy towards new technology, unwillingness to share their perspective etc. In subsequent surveys addition questions to seek this issue can be incorporated and should be addressed accordingly.

Corporate and academic centers had better response rates over others. SBRT practice was prevalent in corporate and academic hospitals; this may represent driving market forces and equipment/staffing distribution. About 70% SBRT users adopted SBRT in 2010. This emphasizes rapid adaptation of SBRT in recent years. Similar trend was noted in SBRT survey in USA.[4]

To evaluate reasons for increase of SBRT in 2010, we did a literature search on PubMed ( with key word SBRT. Year wise filters were applied. About 20 original/review articles were published in 2009 when compared to previous years where 8-9 articles were published yearly. This increase in SBRT publications in 2009 can be one of key reasons for increase in SBRT practice in same period.

ROP's practicing as SBRT specialists treated more number of SBRT patients over others (31 vs. 5). This is a representation of selective preference for SBRT experts on behalf of patients. As expected lung was most common site of SBRT practice followed by prostate and liver.

Ability to deliver higher radiation doses was key reason for adopting SBRT whereas to remain competitive/gain advantage was next important reason. Though it was not a part of survey questionnaire, reported literature suggests SBRT in lung cancer more economical and better cost benefit ratio as compared with conventional fractionation schedules.[7]

Lack of necessary infrastructure was major reason for not adopting SBRT. Non-availability of required treatment modality (radiation therapy machines, motion management techniques, image guidance) was more prevalent than non-availability of diagnostic modality (CT/MR/PET for delineation, availability of hybrid imaging); this could be because of difference in investment. Non-availability of required treatment modality was more prevalent in public institutions. Quality assurance and radiobiology are prominent challenges in SBRT.

Immobilization and motion management was an important issue especially in thoracic and abdominal tumor. In our study respiratory gating, abdominal compression, real time tracking were commonly used techniques. In room volumetric imaging was most commonly used over in room planar imaging. These findings corroborate with US and Japanese survey where compression methods are more common.[4],[5] Surprisingly 60% ROP's did not respond to this questions of dose prescription (isodose line vs. isocenter) suggesting probable lack of confidence to this question.

In recent past European organization of research and treatment in cancer and Canadian association of Radiation oncology have put forward SBRT practice guidelines.[8],[9] No clear policy or consensus was noted amongst ROP's regarding follow-up timing, frequency and imaging at follow-up. Nearly, 85% responders expressed need to establish SBRT consortium India. Responders perceive this consortium may help set guidelines, provide procedural recommendations, dispense knowledge and promote updating of ROP's over SBRT regularly. Comparison of SBRT practices in India with developed countries is detailed in [Table 2]. SBRT use is more common in developed countries and was adopted a year earlier.
Table 2: Comparison of SBRT practices in India with developed countries

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In our survey, 95% SBRT users were planning to increase SBRT use and 95% SBRT non-users were planning to adopt SBRT in practice. Findings suggest developing countries have a huge scope of SBRT adaptation in clinics. In response to survey question ROP's suggested education physicians, updating surgeons with SBRT, informing patients about SBRT may help to increase SBRT use.

Collaboration with international organization can be helpful. Organizations like international atomic energy agency can offer financial and technical support to developing countries. Technical support strategies such as formal trainings, practice guidelines, monitoring will be useful.

 » Conclusions Top

To summarize, the first survey in India regarding SBRT use pattern is presented. This will enlighten current prevalence, patterns of SBRT and perception of ROP's. This information could be useful to develop future SBRT policies in Indian settings. SBRT consortium can prove vital to improve standards of SBRT and maintain database.

 » References Top

Timmerman R, Paulus R, Galvin J, Michalski J, Straube W, Bradley J, et al. Stereotactic body radiation therapy for inoperable early stage lung cancer. JAMA 2010;303:1070-6.  Back to cited text no. 1
Katz AJ, Santoro M, Ashley R, Diblasio F, Witten M. Stereotactic body radiotherapy for organ-confined prostate cancer. BMC Urol 2010;10:1.  Back to cited text no. 2
Munshi A, Krishnatry R, Banerjee S, Agarwal JP. Stereotactic conformal radiotherapy in non-small cell lung cancer-An overview. Clin Oncol (R Coll Radiol) 2012;24:556-68.  Back to cited text no. 3
Pan H, Simpson DR, Mell LK, Mundt AJ, Lawson JD. A survey of stereotactic body radiotherapy use in the United States. Cancer 2011;117:4566-72.  Back to cited text no. 4
Nagata Y, Hiraoka M, Mizowaki T, Narita Y, Matsuo Y, Norihisa Y, et al. Survey of stereotactic body radiation therapy in Japan by the Japan 3-D conformal external beam radiotherapy group. Int J Radiat Oncol Biol Phys 2009;75:343-7.  Back to cited text no. 5
Kundu S, Mathew A, Munshi A, Prabhash K, Pramesh CS, Agarwal JP. Stereotactic body radiotherapy in early stage non-small cell lung cancer:First experience from an Indian Centre. Indian J Cancer 2013;50:227-32.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
Lanni TB Jr, Grills IS, Kestin LL, Robertson JM. Stereotactic radiotherapy reduces treatment cost while improving overall survival and local control over standard fractionated radiation therapy for medically inoperable non-small-cell lung cancer. Am J Clin Oncol 2011;34:494-8.  Back to cited text no. 7
Sahgal A, Roberge D, Schellenberg D, Purdie TG, Swaminath A, Pantarotto J, et al. The Canadian association of radiation oncology scope of practice guidelines for lung, liver and spine stereotactic body radiotherapy. Clin Oncol (R Coll Radiol) 2012;24:629-39.  Back to cited text no. 8
De Ruysscher D, Faivre-Finn C, Nestle U, Hurkmans CW, Le Péchoux C, Price A, et al. European organisation for research and treatment of cancer recommendations for planning and delivery of high-dose, high-precision radiotherapy for lung cancer. J Clin Oncol 2010;28:5301-10.  Back to cited text no. 9


  [Table 1], [Table 2]


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